Orthopedic Coding Alert

Guest Columnist: Catherine Brink, CMN, CPC

You can set yourself up for clean claims and stop expensive mistakes. The key Know how to accurately assign the right E/M code for your urologist's hospital care.

If you ever find inpatient E/M coding tricky, the answers to the following five questions may help you submit your claims with fewer headaches and better reimbursement odds.

Limit E/M Charges to Once per Day

Question 1: If the orthopedic surgeon provides an office-based E/M visit and then later in the day admits the patient to the hospital, how can we get reimbursed for all of our work? Do we have to write off the other E/M services that weren't related to the inpatient admission?

Answer 1: You don't have to write off the outpatient E/M visit, but you are correct that you can only charge one E/M visit every 24 hours. Therefore, the work that the surgeon performed during the office E/M visit that occurred earlier in the day should be considered when selecting a code for the hospital admission (99221-99223), assuming that the surgeon has a face-to-face encounter with the patient during the admission that day.

The combined E/M components of the office visit and the hospital admission are the keys that help the physician and the coder select an accurate initial inpatient service code.

Caveat: Keep in mind that the rules change if the orthopedic surgeon performed an E/M service in the office on Monday and admitted the patient on Monday, but did not have an actual face to face inpatient E/M service until Tuesday. If that occurred, you would charge for the E/M office service on Monday and the hospital inpatient admission on Tuesday, since these services did not occur on the same date.

Determine Inpatient or Outpatient Status in the Hospital

Question 2: A pulmonologist admits a patient to the hospital. The patient suffered a punctured lung during a motorcycle accident, but the patient also has severe pain in his legs and his left shoulder. The pulmonologist requests a consultation from an orthopedic surgeon prior to the admission. Should the surgeon report a consult, an initial inpatient visit, or a subsequent care hospital visit?

Answer 2: If the pulmonologist requests a consultation from the orthopedic surgeon asking about the severe pain in the legs and left shoulder, then the E/M service should be documented and charged as a consultation, assuming the surgeon correctly documents the required components of the consult codes.

The question is: Should you charge an inpatient consultation (99251-99255) or outpatient consult (99241-99245)? To determine the answer, first find out the status of the patient when the orthopedist rendered the consultation.

The solution: If the patient was admitted to observation status? the consultation would be an outpatient consultation. If the patient was formally admitted as an inpatient, you should report an inpatient consult code.

Only 1 Physician Should Report Discharge

Question 3: A family practice physician admits a patient for treatment of a dislocated elbow, and then consults with an orthopedic surgeon, who follows the patient through the episode of care. Both physicians want to report the discharge. Can they split the discharge billing? If not, who should report it?

Answer 3: It sounds as if the family practice physician is the admitting attending physician. Therefore, the attending physician is the physician who reports the discharge code (99238-99239). According to CPT, under instructions for Hospital Discharge Services,To report concurrent care services provided by a physician(s) other than the attending physician, use subsequent hospital care codes 99231-99233.-

However, if the orthopedic surgeon performed a surgical procedure for the dislocated elbow (for example, 24620, Closed treatment of Monteggia type of fracture dislocation at elbow [fracture proximal end of ulna with dislocation of radial head], with manipulation), any subsequent hospital care and discharge services would be part of the postoperative global surgical period, and there would be no charge for subsequent hospital care or discharge services within the global surgical period.

Say Yes to Same-Day Hospital Discharge, Nursing Facility Admit

Question 4: Can the orthopedic surgeon report a same-day hospital discharge and nursing facility admission? It seems as if the two services have overlapping components. If they are both billable, how can the practice ensure that the physician's documentation is thorough enough?

Answer 4: Yes, an orthopedic surgeon can perform and bill for a hospital discharge (99238-99239) and a nursing home admission E/M service (99304-99306) on the same day. To justify billing for both, the orthopedic surgeon must perform and document both services.

Documentation tip: The hospital discharge documentation must support billing for the discharge service. Remember that discharge codes 99238 and 99239 are time-based, so the documentation should include the amount of time of the discharge service as well as what services the physician provided (for example, discharge orders, instructions to patient, any face-to-face encounter, etc.)

A nursing home admission service requires all three key components (history, exam and medical decision-making) to be performed and documented. The complexity of these key components determines the code charged (for instance, 99304 requires a detailed or comprehensive history, detailed or comprehensive exam, and straightforward or low-complexity medical decision-making).

To bill for both services, you must make sure each service is performed and documented separately by the orthopedic surgeon.

Consider Internal E/M Audits

Question 5: Our orthopedic coder noticed that one of our surgeons reports 99232 all the time. How can she determine whether these visits are being coded accurately or whether the surgeon is just picking the code in the middle to stay safe? If she finds inaccuracies, what should she do?

Answer 5: You and/or the coding staff should audit the urologist's subsequent hospital services, preferably a concurrent or prospective audit (meaning that you audit the claims before they are submitted to insurance) to determine which level of service the physician actually documented. 

If your audit determines that his documentation does not support level-two subsequent hospital services, you should have a one-on-one session with the physician to educate him on the differences between a level-one and a level-two hospital subsequent care service, as well as the difference between a level-two and level-three service.

If you perform such an audit, you can use the physician's current documentation to illustrate why his documentation did not meet 99232 requirements. This will ensure that the physician understands how to appropriately document subsequent hospital care services that he renders.

You may find that the physician is underdocumenting rather than overcoding his subsequent hospital care services. If he is overcoding or undercoding, he is noncompliant. In addition, if he is undercoding, he may be  losing reimbursement for his services. Through education sessions, you can ensure that the physician understands how to appropriately document the services he provides.

Watch Out: Don't just make this a one-time audit.After the education sessions, you should monitor the physician's documentation of subsequent hospital care services. If you find incorrect levels charged, have another education session with the physician and repeat the monitoring and auditing process until he learns to accurately document the level of service provided.

Note: If your audit determines that your physician's documentation doesn't support the level of subsequent hospital care, he may be making the same error in his office E/M services. You may want to perform an audit of these as well.  

Catherine Brink, CMM, CPC, is the president of Healthcare Resource Management Inc., a practice management consulting firm based in Spring Lake, N.J.